Note: Not this kind of white coat. Who’s a good boy!?!? You’re a good boy!!!

In recent years, there’s been an interest among veterinarians in reducing fear and stress for our patients. This is not because animals are becoming softer, thin-skinned millennials, but due to a greater awareness and concern for our patient’s emotional states. Which is great and I have no problem with that! But as so often happens, there are a lot of products and services that are now being marketed specifically for fear reduction before we have good evidence for most of them. What’s the science-based argument for any of these? There is a fair amount of research and fear and stress in dogs and cats, but very little of it directly involves the veterinary clinic, and (spoiler alert) there’s almost none directly investigating fear-reducing interventions.

Why is fear in the vet clinic a problem?

One thing that appears obvious and is backed up by research is that most pets are afraid when they come to the clinic, almost 80% of dogs in one study. Sometimes painful or scary things are done at the clinic, but often just being on the same block as the vet is enough to cause the Shih Tzu shivers. This fear response doesn’t benefit any of the parties involved. Pet owners don’t wants to see their animal in distress, veterinary personnel don’t want to feel like they are torturing their patients* (although some should be feared), and the pets themselves prefer to not be in a state of terror. Beyond the ethical unpleasantness of terrifying the animals we’re trying to help (I’ve unfortunately literally scared the crap out of many pets), increased fear and stress can have negative physiological consequences. While’s it’s unclear exactly how this relates to any specific diseases or conditions, if there is any effect, it’s probably not a good one! Fearful animals are also more willing to bite or scratch, which can lead to serious injuries to people and pets. There are plenty of animals that can’t even be examined without sedation, and I’m not just talking about dangerous large animals. If we could reduce fear in our patients, it would make life better for everybody.

How do we define fear in the vet clinic?

One of the big obstacles is that fear, unlike midichlorian count, is a difficult thing to measure. Although we all know it’s there, there is a bewildering amount of different measurements used to research fear. Consider the many different types of behavior that could signal an animal is afraid: trembling, panting, freezing, hiding, even urinating and defecating. Most animals don’t display all of them and few of them are specific to fear only, which makes it hard to get an objective “fear score”. Many metrics have been used (stress hormone levels, vital measures, behavioral analysis, owner surveys, etc.) but there is no universal assessment technique. This muddies the waters in fear-reduction studies since we are sometimes comparing apples to salivary cortisol levels.

What are the interventions that reduce stress of fear during veterinary visits?

This review covers a lot of what we know contributes to fear and stress in veterinary patients and recommendations for improving the situation. The striking thing about it is that most of the recommendations are based on opinion or extrapolated from other research findings. In the absence of any of other data, this isn’t necessarily bad. There are a lot of obvious things that should help, such as having a separate waiting area for dogs and cats (so that the two-pound abominations of nature known as teacup chihuahuas don’t feel like they’re surrounded by tigers). The late Dr. Sophia Yin wrote extensively on some extremely useful strategies for reducing fear in the clinic (for example, see this helpful guide on how to greet a dog) which have the support of most veterinary behaviorists. But given the aggressive marketing of low-fear strategies, shouldn’t we have tested and proven interventions?

I tried to find what I could in terms of clinical trials for fear and stress reducing strategies, but there’s depressingly little in the literature. I also wasn’t able to access every article or evaluate all the methodologies, and a systemic review this ain’t. What follows is a sparse collection of small clinical trials and extrapolations, which is as of right now the state of our evidence in reducing fear in dogs and cats visiting their veterinary clinics.

Handling techniques

Modifying some of the experience of being at the vet might be low hanging fruit, since much of what triggers fear in animals has nothing to do with painful stimuli (for example standing on a scale). Manual restraint, or “patient handling” is often necessary for giving vaccines or collecting blood samples, and varies enormously between different clinics. Despite a great deal of specific recommendations for “low stress” manual restraint, there is only one tiny study showing that these techniques showed some beneficial effects for dogs in a veterinary clinic. Owner-driven methods such as carrier training (a desensitization technique where low-grade gradual exposure to a typically fearful stimulus eventually diminishes its scariness) appeared to be beneficial for cats. There is a lot of potential here but very little that has been explored yet.

Drugs

When it comes to reducing fear in the short term (i.e. a 30 minute veterinary visit), oral sedatives are an excellent option because they can be given at home, are generally safe, and don’t last for very long. Despite there being a variety of drugs being commonly dispensed for this purpose, we have very few studies on pharmacological fear reduction in dogs and cats coming into the clinic. Both gabapentin and trazodone passed small controlled trials for cats but to my knowledge there are no trials in dogs. There are drugs that are effective for fear reduction in dogs (usually for loud sounds like thunder or fireworks)** and that would probably work just as well for veterinary visits, but no one has studied it yet.

Music

Of course the idea of using drugs to chillax pets conjures up sad visuals, so there is always a desire to look for “alternative” strategies. Nothing is more alternative than music therapy, and I’m not just talking about The Shins. Music has been looked at a lot for fear reduction in animals, but unfortunately there’s little to suggest that it would benefit pets in the clinic. To my knowledge there’s only one study on dogs in the veterinary setting, and it did not show any beneficial effect. There are some other studies in shelter dogs, including one showing they appear more relaxed when listening to Beethoven rather than Judas Priest (presumably exposing the animals to Nickelback was deemed too cruel to receive ethical clearance). In cats, there are no trials using music during exams, but there may be some physiological effects from auditory stimuli during anesthesia. It’s certainly an interesting and appealing intervention, but we need some more evidence.

Somewhat similar to pheromones, various scents have been evaluated for their effect on the behavior of dogs and cats, mostly in shelter situations. Because pets are very sensitive to olfactory stimuli, it’s possible that certain scents could affect behavior, but to my knowledge there is no routinely recommended scent or diffuser in veterinary practice. I suppose you could say we have no “common scents”.

Miscellaneous

Surprisingly, that’s the extent of the research that I could find. Similar to the names of Usidore the Blue though, there may be other types of fear-reducing strategies that I just have not heard of yet. There are a fair number of therapies that have been evaluated for fear reduction with loud noises, but nothing specific to fear reduction in the veterinary clinic. Pressure vests,*** homeopathy, acupuncture, and nutraceuticals (1, 2) all have small studies of varying quality in noise phobia trials. It’s hard to say exactly what we can extrapolate, but it is a starting point.

Conclusion: I’m afraid it’s not enough

The takeaway here is that there is barely any research on what actually helps to reduce fear in the veterinary clinic. You don’t need peer-reviewed research for every little detail of your life though, and if nothing else, the awareness of veterinary visits causing a negative mental state in our patients will probably ensure that our approach is more compassionate. I am very happy that veterinarians as a community are trying to reduce stress and fear in our patients, but I am also concerned that this genuine and positive movement is being so thoroughly commercialized.

Take, for example, the Fear-Free program, which certifies veterinary practices as “Fear-Free” (starting at around $300 per individual for initial certification). This is a somewhat extraordinary claim, since eliminating pet fear would seem impossible even under the best circumstances. Although there are some very good people behind this movement and they appear to be well-intentioned and science-based (they do offer research grants), there is a distinctive lack of evidence showing that their methods are actually effective. It’s not enough to extrapolate from the few studies of fear in veterinary patients and claim that these strategies are proven. We need pragmatic, tested strategies to prove that their certification is more than effective marketing.

* I’m not sure if the awareness of causing fear in our patients contributes to job dissatisfaction, but since veterinary burnout is such a pervasive problem, it seems at least plausible that reducing fear would also lead to happier veterinarians.

**The thunder noise model is actually a pretty good one for fear response in dogs. Both thunder noise and visiting the vet can stimulate extreme fear, are acute situations, and affect most dogs. We have a number of trials showing variable efficacy for all sorts of thing from drugs to pressure vests, to nutritional supplements for fear reduction in dogs. Although there are important differences, we can draw from this body of research when coming up with strategies.

***The Royal College of Veterinary Surgeons has an excellent website full of evidence reviews.

Posted by Greg Bishop

Greg Bishop is a veterinarian in Southern California who works mainly with dogs and cats. As a fan of the SBM blog, he sees the enormous amount of bad science and information in the field of veterinary medicine as an opportunity, not a problem! But also a problem.